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HomeMy WebLinkAbout1437A (8) • WORKERS'COMPENSqTION DECLARATION � I hereby a{firm �hat I have a tertificate of confenf to self � � inaore,or 6 certificote of Workeri Compensofion Insorante,or �6"b�zo ' ,1� Po��Y`N������Y�f(Sec3800,jqb..)F�d CEBOB;REV.1/83� qpp��CATION FOR PERMIT � Company SZ . ❑Cerlilied topy is hereby furnished. � � SEWER - SEWAGE DISPOSAL � � . � �Cerrified copy is filed wi�h the counry building tnspection COUNTY OF l05 ANGELES BUILDING AtVD SA�ETY deporlment. . oa�e 8�26I8Tinol�ca�+ T: 7?2`AAmATI FOR APPUCANT TO FILL IN � CONNECTION DATA , CERTIFICATE OF EXEMPTION FROM WORKERS' �iip�� � - . COMPENSATION INSURANCE � - ��ss 8 � eather►ro� 5TA"°" ��" . (Thia secr�on need no�be comple�ed i(the work involved by�he i�i�TY M,,,r+�ac yE�rs�r�[ � UPOE� RE � q permir is fd one hundred dollors(f100)or�ass.) IEf.IGTHFRdN 1 ce�ii(y�hat in the per/ormance of the work fo�which ihia taossssr. �Y�����T� S lvan Gl en Y.. �„� p.l. M.l.TO P.l. permir Is issued,I_aholl no�employ ariy person in any manner - p�� so oe ro become:ubject to the Workers'Companseiion lowz. pW�q Anden G co.u.v.nio. �oa�+o. �d Z' Do�e Applicont Aoort[ss Po �ox..332 TQUNKPFRNJTNO, ROAOPERM11N0. NOTICE TO APVLICANT: I(, ofler making rhis Cm�ifica�e of ��T� - 818 6 � AFFiOAVIi W4IVER fNSEMENT rtetoco.n�a*a.rap. oare ' �pfion, you should become subjecr ro the Workers' C+OV1II$ r[�.r�+o ensation avisions of the Lobor code, ou must fonhwith �EGAI w v o�xa�m�or, lOTNO. HNN.ORST.WIpENING c�.,ply with such provisions or�h�s pe�mit sholl be deemed revoked. aiocK iRACf ��1 SiAiEENCROA�MMENT �IiCENSEU CONTRACTORS DECIARATION ^'o a&°�s. . °EQMi�r�,o. sae or ioT r+ow ow�oT I hereby a(firm Ihot I om licensed under provisions of Chopter �� ' 9(commencing wi�h Seciion 7000)of Division 3 of ihe Busi- eu�m�n�s p��p�5 ness ond Professiona Code,and my license is in full force ond eHec�. r� coraraacroc tOr�NeaioM cN�RGt r� - Licanse N�mber Q 1 QS�7 �i�,��OSS ��4 AODREu 822 e 31 REIMBl195FMENT FfE a �O�MpttOf �• �eemanpo,e � 8/26/86 • D�SiY�CTNO. GQWv µ4i VFp�E55FDBY Q . ��t� Alta Lom�.�. 1 80- BK ,� u S�nrE uc. la 'C ❑I om exemp�under Sec. 01 the L.A.Co. i��Ns[/.q. $$� ttass Plumbing Code and/or Sec. of fhe 1tO� �`'�Riv�iOnl OF wORK c�E FNqL O �a�s��weR ea��er�r�ro 1 � D�iE r L VALIDATION 6 B.8 P.Code(or�he following.eason °UBLK�'"ER . . MIC ANIt,$EEP�GF WT OR FINAI Z vii5 PNU/OR d1AINF1ElD ' D07G MOVS[$EW(R CONNfCfING TO eY RlNA DISPDSAL SY TEM � S191101ur! � CONNECf ADDITIONAL&DC.OQ � OWNER•BUIIDER DECIARATION �ro"°°u s�`^ER . pV[pFIOW SEEo1GF RT.OP�iNiiELD '�� [��7 A I l+e.eby affirm thal I am exempt from the Contractar's license EXTN.,CESSq'10L pRYW[t{,MAw10lE lnw for the following reason(Secton 7031.5�BViSB@55 Ol7d PIO- N�E4.REPIIIR pl/.lJ1NDp�IqUSE �;•• e s � Q ons Code�: scweR aa o�scosu SrsnM � _ as ownar of the property,or my employees with wages as � ° •2 7 .Jr O their sole compenmtion,will do�he work and ihe anuct�re is not intended or offerad for wle(Section 70a1,Business e e e 2�,5�� and Professions Code�. OWNER�S Pe�mif t ❑I,as ownar of the pioperty,am excluzi�ely tomroctf�g wfth AUTMORIZATION TOTAL FEE `L Q 0�.2 9•'$6 licensed conrrac�ors to constrvct the projact($ection 70ar� I HI.V[A7 THI$OAtE A CONi4ACi WILH.fNE 11ERFIN WIMIFD CONiiACfOR f0 B�siness and Proten�ons Code). coH�Fcr THe naovc o[sca�e�o exisnnie owewn�7o r�vueuc s�v.Ec. CONSTRUCTION LENDING AGENCY ► I hereby affirm IFot ihere is a conslrVction lending ogency SIGNE�THIS DAYOF 19 . for fhe performance of �he work for which this permit is a'''�R� OWNF A M ����sa�sa�.3oa�,c��.c.�. �2 5 eee wo o a I,oma A Lender's Name Lender's Addresa I eenify that I hova read this opplicotfon ond srote�hot+he ' above Informofion is correct.I ag�ee to comply with all Co�nry . . ' � ordinonces and Srole laws regulating Plumbinq ond Sewera, � � ' and hereby aurho�ize represen�otives ot this County to eMer . upon the above-menlioned property for inspettion p�rposes. � �� �1Qp�� ��d��G Signoture o/�ermittee Date " SEF REVERSE FO�EXtIANATOM IANGUAGE , ' , ' � ' . . . _ . . � � yc :; m r� mn 7 • � � . ..): o . '� Zv �O . • . , � . o� D h �.'.'+ �' V� _7 : .. . . 7(� »` � C'7 ._ ' � I __� C1 f �� ,� �Y G ti .` � . ' : . ',. " • � . . . , e� 7 Ji �•D � �in 01• 'ro . � �i �n ��" C;.v �� D n `ci 1] . i- ' � ' . � I . ��C 7' " � . • .. I" m.D ^'W .'•t �.;; ��i, a 0 ; . � � . .' ; � _'_- �� }D �',' �` Cn � = i ; , . 1 � I i � . v❑ .'� $ r . , . __..._ : ... ✓�. ��u � V� - ,. m ` � � ' 1 � , . � ' ' �1 � '�'� ... , .� . Q ' i � I I � ' � � .� � . • ' , Z ,_.. -- '-..i .. 1 i• I •'- j . N y . . 7 :. O '� f%J` --- - ; � � , . ..-", I � I � .. ' .. ~' r•_ I . � • . , � � � p . .- : � , M,� � �' , . ' • ` ' . � ' � . � ' i _' I � � �' �+' y . � - . . �.. 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